HAI Evaluation Guide 2011 ENG

7/30/2019 HAI Evaluation Guide 2011 ENG

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Washington, D.C.

2nd Edition, 2011

PAN AMERICAN HEALTH ORGANIZATION

Health Surveillance and Disease Prevention and Control Area

International Health Regulations, Alert and Response and Epidemic Diseases


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Acknowledgments

This guide was produced based on an original idea by Gabriel Schmunis and counted with the

contributions of Latin American experts in prevention and infection control -

Silvia Acosta de Gnass, Maria Paz Ade, Laura Araya, Maria Isabel Gonzalez Betancourt, Pola

Brenner, Teresa Camou, Liliana Clara, Erna Cona, Alessandra Santana Destra, Silvia Fonseca,

Amparo Gordillo, Jorge Matheu, Fernando Otaiza, Pilar Ramon- Pardo, Roxane Salvatella, Gabriel

Schmunis, Valeska Stempliuk, Maria Enilda Vega, Natallie Weiller and Martn Yagui.

This publication has been made possible by the sponsorship and cooperation of the United States

Agency for International Development, Bureau for Latin America and the Caribbean, Office of

Regional Sustainable Development (grant LAC-G-00-07-00001-00) and the United States Centers

for Disease Control and Prevention (Cooperative Agreement Number 5U51/CI 000450-04).


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Contents

Preface.....................................................................................................................................4

Introduction ............................................................................................................................4

General considerations .....................................................................................................4

Instructions for application of the rapid evaluation guide for nosocomial infection

programs .................................................................................................................................6

General instructions..........................................................................................................6

Instructions and recommendations for interviews ..........................................................6

Instructions and recommendations for document review...............................................7

Instructions and recommendations for direct observation .............................................8

Specific instructions ..........................................................................................................8

Written Report ..................................................................................................................9

Records .............................................................................................................................9

People to interview...........................................................................................................9

Proposed program ..........................................................................................................10Glossary.................................................................................................................................10

Rapid evaluation guide for nosocomial infection programs ................................................15

AREA: ORGANIZATION ..........................................................................................................16

AREA: EPIDEMIOLOGICAL SURVEILLANCE OF INFECTIONS ..................................................17

AREA: MICROBIOLOGY..........................................................................................................18

AREA: INTERVENTION STRATEGIES ......................................................................................20

AREA: STERILIZATION AND HIGH-LEVEL DISINFECTION .......................................................22

AREA: PERSONNEL HEALTH...................................................................................................23

AREA: HOSPITAL ENVIRONMENT AND SANITATION ............................................................24

AREA: INEFFECTIVE PRACTICES .............................................................................................26

AREA: NEONATOLOGY ..........................................................................................................28


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PrefaceThere is no doubt that infections associated with health care (nosocomial infections) pose a

problem, affecting approximately one out of twenty hospital patients. Programs for infection

prevention and control have demonstrable benefits in reducing related morbidity and mortality

and hospital costs. One of the best ways to improve the effectiveness of a program for prevention

and control of infections is through systematic and rigorous evaluation of the structural,

functional, and practical elements that have to be implemented in hospitals. Evaluations, whether

they are external or internal, make it possible to identify those areas requiring additional efforts to

comply with standards, to evaluate the strengths of institutions in comparison with their peers,

and to set priorities for interventions from the national level.

Evaluations also have formative effects on human resources of the institutions that are evaluated.

There can be an immediate effect in improvement or correction of practices, in particular, for the

prevention of nosocomial infections. However, the lack of available tools has meant that

evaluations of the programs and practices of prevention of communicable diseases have not beenmade part of program routine. PAHO developed this tool in 2005, and it has been validated

through its application in the field in a number of countries of Latin America. The application of

this tool is thus based on direct observation of practices in visits carried out jointly by national and

international professionals.

After five years of the first edition, the increase of scientific evidence has made it necessary to

update the original instrument, while maintaining the same purpose and functionality. This second

edition also includes a specific annex on neonatology, expanding its objective and scope. The

addition of this new area comes at the request of the countries, given the large number of hospital

infection outbreaks in these services. It is expected that this guide will maintain its usefulness and

be used within the health services to direct implementation and maintenance of programs andpractices for control of nosocomial infections.

IntroductionGeneral considerations

The purpose of this guide is to provide orientation for hospital directors on review and

improvement of the nosocomial infection programs that all such facilities should have. According

to the experts, a well-developed program in the areas currently considered necessary will contain

the components and characteristics described in this guide. It is recommended that, before an

evaluation, hospitals to be evaluated be informed about the visit and its objectives, and that they

have access to this guide.


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The purpose of this guide is to provide a general overview rather than specifics on the status of

Infection prevention and control (IPC) activities. Therefore, it does not consider the risk of

individual patients or specific cases. By nature, it is intended only as an instrument to provide

support for an external assessment of the status of the program. It should not be considered an

accreditation system. Furthermore, it does not consider other aspects related to care outside of

surveillance, prevention, and control of nosocomial infections.

The development and use of the first edition of the Guide were possible thanks to the support and

cooperation of the Office of Regional Sustainable Development, Bureau for Latin America and the

Caribbean, U.S. Agency for International Development and the Centers for Disease Control and

Prevention of the United States of America and the experts of several countries. For its

development, specialists in nosocomial infections and microbiologists of several countries met to

lay out the principal and essential points that all hospitals should implement in terms of hospital

IPC. This guide was applied successfully in 67 hospitals, including public, private, and other

hospitals, in 7 countries of the Region of the Americas, involving national and international experts

and PAHO staff. Although the programs evaluated presented quite different levels of compliance

for the indicators evaluated, the contents of the guide were sufficient for evaluating the differenthospitals and their programs for prevention and control of nosocomial infections

1.

After 5 years of the first edition, given the additional scientific knowledge accumulated during this

period, the updating of the guide became necessary. Again experts from several countries were

invited to participate. The result is a second edition that maintains the general evidentiary

principles and applicability of the previous edition. This edition also includes annex for for

prevention of infection in the neonatology area.

Description of the guide

The guide provides information on a number of aspects that, according to a group of LatinAmerican experts, should be included in HAI prevention and control programs. These aspects have

been organized in eight areas that include similar topics. In each area, some components

considered to be essential in a good infection program have been selected. In each component,

the characteristics considered to best describe an acceptable component have been established.

Then, indicators have been established so that the presence of the characteristics could be

considered objectively. A single characteristic may have several indicators and a single component

may have several characteristics. One or more verifiers (suggested verifiers) have been proposed

for each indicator. These simply offer orientation or sources of information for the evaluators that

can be used to determine whether a certain indicator is present. The evaluators can use other

methods to establish the presence of indicators.

According to this guide, evaluation of the nosocomial infection program is based solely on the

presence of indicators. The existence of the characteristics and components is based on analysis of

the indicators used for evaluation.

The only exception to the above is the INEFFECTIVE PRACTICES area, in which the presence of

any of the indicators is considered in a comment to the report.


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Instructions for application of the rapid evaluation guide fornosocomial infection programs

General instructions

This guide is designed to be applied within a short period of time (approximately 8 hours per

person with one team of 4 people).

All actions carried out during an evaluation have a well-defined purpose that should be madeknown during the activity.

Take written notes on your observations at the time. Do not rely on your memory. The written report must be compatible with the oral comments made during the visit.Instructions and recommendations for interviews

This process includes three main types of interviews:

. Initial interview: This interview is usually with the hospital director, who may or may notbe accompanied by other people. The objectives are as follows:

Introduction to the local authority. Meet the people who will accompany the evaluators during the activity. Become familiar with the general characteristics of the hospital. Explain which activities will be conducted in the hospital during the evaluation. Set a time for the final meeting. Confirm that the local authority has consented to the activity.

. Technical interviews: These interviews are with professionals who perform differentactivities in the hospital. The objective is to obtain specific information related to the guide.

In order to make the most of these interviews, the following is recommended:

You should always be accompanied by a professional from the hospital Interview the person in charge of the unit or activity. A meeting with personnel working

under him or her should be held only with his or her consent.

Introduce yourself and explain the reason for the interview. Tell them what information is required.

. Final interview: This interview is usually with the hospital director, accompanied by otherpeople. This objectives of this interview are as follows:

Report the main findings of the observations.o Briefly summarize each area, highlighting aspects that are partially or fully

acceptable as well as those that can be improved. Use clear examples. Avoid going

into detail.

Compile any information that was not included previously. Receive comments and clarifications on your observations. Thank the facilities and the appropriate individuals for having participated in the activity.


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It is recommended strongly that the evaluation team meet alone for a few minutes before the final

interview and agree on the points that will be dealt with.

Instructions and recommendations for document review

Some of the information will be obtained from documents that directly or indirectly contribute

data that can be used as a basis for determining compliance with the characteristics in the guide.

Document review tends to be a long and complex process. For document review:

Focus the document review on the objectives of the guide. Request that your local contacts indicate where the information is found in the documents.

Review by a person unfamiliar with the local documentation system may be tedious and

fruitless. Be explicit about your needs.

Avoid requesting a particular document. It is preferable to request documentation for theactivities. Each hospital has its own form of documentation.

For example: In order to find out about training activities, avoid requesting committee

minutes since the information needed may not be found there. However, if you requesta list of training activities carried out, there may be different types of documentation (e.

g., annual summaries of activities and specific training reports).


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Instructions and recommendations for direct observation

Evaluation of many of the characteristics is based on observation of how activities are conducted

in practice.

When direct observation activities are conducted, tell your contacts your expectations beforebeginning observation. After completing the observation, summarize whether what you found

met expectations or the practices did not meet the requirements.

Be cautious about your comments and your reactions to noncompliance with best practices,particularly because the visits are often accompanied by personnel who may have a partial or

distorted understanding of the practices.

If you observe failure to comply with techniques or inappropriate practices, it is important totake note and possibly mention it at the meeting. However, this does not necessarily mean

that it represents a trend unless the practice is repeated.

Specific instructions

Some areas have special conditions to be evaluated.

AREA: INTERVENTION STRATEGIESThis is one of the most important areas of the evaluation. It is also usually the area in which

there are the greatest numbers of observations. In order to evaluate this area, fill out the

PREVENTION AND CONTROL STRATEGIES RECORD FORM. Each indicator refers to the

summary of one of the columns on the RECORD FORM.

The evidence-based concepts used to evaluate the preventive strategies are only some of the

best well-known and least controversial concepts. Therefore, they should be included in the

usual practice of all hospitals.

AREA: INEFFECTIVE PRACTICESThere are a series of practices that have been introduced in the past in hospitals to prevent

infections but which do have bases to support their effectiveness. That is, it has been

documented that they do not prevent infections. In some cases, there is even enough

information to advise their elimination because they increase the risk of infection.

In this evaluation it is enough to take note andconfirmthe presence of an ineffective measure

that increases the risk of infection in order to include a comment about it in the final review

and the written report. Information on the presence of ineffective measures may be acquired

from multiple sources. It often occurs by chance during observations in the clinical units.

AREA: NEONATOLOGYThis area includes all aspects of prevention of hospital infection, as well as prevention of

vertical transmission from mother to child. Experts agree that these points should be included

in hospital practices for IPC.


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Written Report

Instructions and recommendations for the preparation of the report

When the field activities have been completed, a final written report should be prepared. It is recommended that the report be written on the same day as the evaluation was made,

particularly if more than one hospital has been evaluated that day.

This is an activity that should be carried out by the entire team. If more than one hospital hasbeen evaluated on the same day, it is recommended that the hospitals be analyzed one at a

time.

Records

Indicate whether or not each indicator in the guide is present by recordingYES,NO, orPARTIAL.Whenever NO or PARTIAL is recorded, a brief written description of the actual status should be

provided so that there can be records for local follow-up. UNEVALUATED should only be recorded

in extraordinary circumstances, and the reason should be explained.

People to interview

Director Person in charge of the IPC Program or Committee IPC nurse Medical epidemiologist Microbiologist Sterilization supervisor Unit chiefs for intensive care, pediatrics, and surgery Head of nursing Personnel health supervisor


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Proposed program

Activity Estimated

duration

minutes

Number of

evaluators

Objective

Initial interview 40 All Presentation set final meeting.

Meeting with technical committee 90 to 1201

recommended: all

Review of information, documents,

evaluates the organization and

surveillance.

Sterilization 45 to 60 1Evaluate the sterilization and

disinfection processes.

Laboratory 30 to 45 1 Evaluate microbiology.

Intensive Care Unit 30 to 45 1

Pediatrics 30 to 45 1

Surgery 30 to 45 1

Medicine 30 to 45 1

Visit to

services

Other services,depending on time

available.

30 to 45 1

Evaluate intervention strategies.

Integration of the program into

routine practice.

Aspects of the physical plant and

environmental sanitation.Identify ineffective practices.

Meeting with personnel health

supervisor30 to 40 1 Evaluate personnel health.

Meeting with governing body 30 to 60 All Oral report on findings.

Writing report 120 to 180 All Prepare report.

Glossary

access

In this document this refers to the situation in which a hospital

provides a service that is not necessarily directly under it. For

example, it may not have a microbiology department. Rather,

the service is provided by an external laboratory on a timely

basis whenever required. In this case it has access to

microbiology.

annual dischargesIncludes normal discharges, discharges due to death, and

transfers, over the period of a year.

annual occupied bed days

Based on a daily count of the number of patients in the patient

care location. This count is recorded at the same time every

day. Daily totals are summed up at the end of the month, and

monthly totals summed up at the end of the year.

basic HAI indicators Minimum ongoing information that a hospital should have in


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order to determine infection status. The following infections

are included in this minimum: central venous catheter-related

sepsis, catheter-associated urinary infections, pneumonias

associated with mechanical ventilation, surgical site infections

by type of operation, and puerperal endometritis by type of

delivery. These indications may be different if an

establishment has other frequent high-risk procedures.

biological sterilization controls

Biological controls are currently the only available means to

confirm sterilization of an article or to determine the

effectiveness of the sterilization process.

Bowie-Dick test

This is a method for evaluating the effectiveness of the

vacuum system of an autoclave, by measuring the presence or

absence of air or other gases in the sterilization chamber that

can hinder rapid and uniform penetration of the steam into

the contents being sterilized.

chemical sterilization controls

These tests are based on chemical reactions and are sensitive

to the parameters of the different sterilization methods

(saturated steam, temperature, and time). They contain paper

strips printed with ink and other non-toxic reagents thatchange color when the requirements for the process are met.

disinfection

Procedure designed to eliminate pathogenic agents from

articles and other patient care equipment in order to decrease

the risk of infection. Microbial spores are not usually

eliminated. Different levels are distinguished using Spaulding's

classification. High-level disinfection is of particular interest.

epidemiological surveillance

Ongoing information system on diseases (usually infectious

diseases), in the population in order to determine their

frequency, risk factors, morbidity, and mortality, for early

detection of epidemics.

evidenceCertainty derived from studies on a given subject that are

currently considered to be conclusive. This usually includes,


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but is not limited to, several controlled clinical trials with

concordant conclusions.

external performance

evaluation

System for retrospective and objective comparison between

laboratories, organized by an independent external entity.2

goals

Quantified objectives expected to be achieved. They are

usually expressed numerically in ratios, rates, proportions, or

other similar indicators.

guide

Document with recommendations for action on a given

subject. The subjects are usually technical, and the

recommendations are not compulsory.

healthcare associated

infection (HAI)/ nosocomial

infections (NI) /hospital

infections

Infection that occurs during or as a result of hospitalization,

and was not present or in incubation at t he time of patient

admission. This definition does not distinguish between severe

and minor infections, or between preventable and non-

preventable infections.

high level disinfectants with

proven effectiveness

Formulations based on glutaraldehyde, >2%;

orthophthalaldehyde (OPA), 0.55%; hydrogen peroxide, 7.5%;

peracetic acid, >0.2%; hydrogen peroxide, 7.35%. and

peracetic acid, 0.23%; hydrogen peroxide, 1%, and peracetic

acid, 0.08%.

immunization coverage

Proportion of persons vaccinated of the total planned. For this

guide, no distinction is made whether or not the

immunological response to the vaccine was evaluated.

immunization program

Activities designed to vaccinate a given population, which

establishes who should be vaccinated, which vaccines should

be used, dosages, methods, periodicity, and any other relevant

characteristics of immunization.

invasive procedure

Clinical procedure that includes mechanical disruption of the

body's defense barriers (e. g., skin perforation or insertion of

catheters that change the normal flow of fluids.

major surgeries A major surgery is any procedure carried out in an operating


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room that requires incision, excision, manipulation, or suture

of a tissue. It usually requires local anesthesia, general

anesthesia, or deep sedation to control pain.1

management of personnel

with/exposed to infections

Perform rapid diagnosis and appropriate post-exposureprophylaxis following accidents in the workplace

manual

Reference document that organizes and summarizes the

regulations, instructions, procedures, or any other type of

information, usually operational, on a specific subject.

medical sharps box

A container for disposing safely of sharp objects sued. The

medical sharps box should safely contain contaminated sharp

objects: immediately after use; during temporary storage; and

during transport and handling up to the point of final

treatment and disposal.

official document

Document that meets local requirements to be considered

obligatory for familiarity and compliance. At minimum it must

have the signature of the person in charge of the hospital.

orientation program

Organized training activities to ensure that recently hired

personnel are familiar with the hospital's technical and

administrative procedures.

professional Worker with a university education and degree.

programOrganized set of resources and activities to attain a known

end. It also includes objectives, goals, and persons responsible.

routineCustomary practice without a rationale that is performed

according to current practice.

standard Standing order that must be complied with.

sterilization

Procedure designed to eliminate all forms of microbial life

from articles and other patient care equipment in order to

decrease the risk of infection.

structures responsible for the

program

A specific stable unit or service that includes those responsible

for the safety of clinical activities (departments or unit chiefs).

In addition to the individuals themselves, this includes their


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method of communication and the hierarchical structure of

the organization.

supervision

Process of observation for measuring compliance with

standards, instructions, care procedures, or other

characteristics of daily practice.

1 ALIANZA MUNDIAL PARA LA SEGURIDAD DEL PACIENTE. SEGUNDO RETO MUNDIAL POR LA

SEGURIDAD DEL PACIENTE. LA CIRUGA SEGURA SALVA VIDAS. Organizacin Mundial de la Salud.

http://whqlibdoc.who.int/hq/2008/WHO_IER_PSP_2008.07_spa.pdf

2 Curso de Gestin de calidad y buenas prcticas de laboratorio. II Edicin, Washington, D.C.,

2009.http://new.paho.org/hq/index.php?option=com_content&task=view&id=1077&Itemid=12

73&lang=e


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DESCRIPTIONOFHOSPITAL

Evaluationdate:

Nameofthehospital:

City:

Country:

Administrativestatus:

state

private

university

Oth

er:

Beds:

Annualdischarges:

Annualoccupiedbed

days:

BedsinIntensiveCare

Unit(ICU):

Microbiologylaboratory:

ICUbedsforadults:

Numberofisolations/year:

ICUbedsforpediatric

s:

Numberofantibiograms/year:

ICUbedsforneonatology:

Cl

inicalService

#Annualdischarges

#Annualmajo

rsurgeriesor

childbirths

Su

rgery

Obstetrics

Pe

diatrics

Internalmedicine

Neonatology

Adultintensivecare

Marktheclinical

orsurgical

servicesthatthe

hospitalhas

Othersubspecialties

Namesandpositionsofthepeopleinterviewed:

Namesofevaluators:


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AREA:ORGANIZATION

Components

Characteris

tics

Indicator

Suggestedverifier

Present?

Thereisanoffic

ialdocument*d

esignatingthoseresponsiblefor

IPCinthehospital.

Documentsignedbylo

cal

authority.

Thefunctionsfore

achpersonresponsiblearelaidout.

Documentsignedbylo

cal

authority.

Thestructu

resresponsible*

forInfectionPrevention

andControl(IPC)inthe

hospitalandthedivisionof

responsibilitieshavebeen

defined.

ThepersonnelresponsibleforIPCareatahighlevelwithinthe

institution.

Documentsignedbylo

cal

authority.

Thereareannualg

oals*

forIPCforthehospital.

Officialdocumentofth

e

institution(program,p

lan

orannualreport).

Thereisevidencethatdecisionsaremadetoachievethegoals.

Minutes,reports,or

interventionprograms.

Leadership

IPCfunctionsaredirected

andevaluatedbythe

highestlevelofthe

organization.

Goalsaremonitoredandevaluatedatleastonceayear

bythe

hospitalmanagem

ent.

Minutes,reports,or

annualreport.

IPCEducation

TheIPCpro

grami

s

considered

tobean

integralpar

tofworkbyall

personnel.

Thereisanorienta

tionprogram

*f

ornewpersonneland

this

programisimplem

ented.

Writtenprogramthat

includesIPCstandards.

Reportoncompliance

withtheprogram.

*

SeeGlossary.


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AREA:EPIDEMIOLOGICALSURVEILLANCEOFINFECTIONS

Components

Characteris

tics

Indicator

Suggestedverifier

Present?

PhysiciantrainedinbasicepidemiologyandIPC

Interview,

certificates

Theprogramh

asa

physicianfo

rthe

activities.

#ofphysicians:

Totalhoursperweek:

Interview1

Nursingprofessionaltrainedinepidemiologicalsurveillanc

e,IPC,and

supervision

Interview,

certificates

Theprogramh

asa

nursingpro

fessionalfor

HAIcontrol.

#ofnursingprofessionals:

Totalhoursperweek:

Interview2

Personnel

Microbiologist

Access

*t

oprofessionalmicrobiologist

Interview

Standardizeddefinitionsofmostfrequentinfections

Localdocument

Atleastweeklycase-findinginriskgroups,byreview

ofclinical

historiesandlaborat

orydata

Surveillancerecord

sheets,interview

Case-findingcarried

outbyprofessionals

Interview

Surveillanceisconducted

withactive

data

collectionm

ethods

Standardizeddefinitionsofexposedindividuals(denomina

torsof

rates)andofhowinformationonsuchindividualsiscollected

Localprocedureand

interview

HasmonthlyHAIratesforeachbasicindicator*3

NumberofmonthsInthelastyeartheindicatorwasprovided:

Reports

Annualanalysisandreportonantimicrobialdrugresistanc

e

Report

AnnualanalysisofHAItrendsthatidentifiesproblemsand

proposes

solutions

Report

Evaluationsystem(e

.g.,prevalence)ofthecapacityofthe

surveillancesystemtodetectinfections

Evaluationreport

Surveillance

method

Epidemiolo

gical

information

isanalyzed

todetectHAIproblems

andevaluatetheimpact

ofinterventions

Identifiesepidemico

utbreaksandhasoutbreakreport

Numberofoutbreak

sinthelastyear?

Averagetimefordet

ectionofoutbreaks:

Outbreakreport

Periodicreportwith

analysis,recommendations,andknow

n

distribution

Reportorbulletins

andlistof

distribution

Disseminationof

information

Information

is

disseminatedtoallwho

needit

Up-to-dateinformationisavailableandknowninallthedepartments

involvedinsurveillan

ce

Interviewmanagers

*

SeeGlossary.

1-minimumof10ormo

rehoursaweekCorecomponentsforinfectionpreventionandcontrolpro

grammesWHO/HSE/EPR/2009

2-minimumofonefull-

timeprofessionalper250beds-HaleyRWe

tal.AmJEpidemiol.1985Feb

;121(2):182-205.

3-minimumofatleast8

0%oftheyear


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AREA:MICROBIOLOGY

Components

Characteristics

Indicator

SuggestVerifier

Present?

Identificationofa

erobicbacteriatospecieslevelinbloo

dcultures

Enterococcusfaec

iumandEnterococcusfaecalis

Pseudomonasaeruginosa

Staphylococcusau

reus

Enterobacteriaceae

Report,record,and

laboratoryinterview

Identificationofv

iralagents:

HepatitisBandC

HIV

Adenovirus

Influenza

Syncytialrespiratoryvirus

Rotavirus

Report,record,and

laboratoryinterview

IdentificationofM

.tuberculosis

Report,record,and

laboratoryinterview

IdentificationofC

andida

Report,record,and

laboratoryinterview

Theestablishmenthas

access

*t

oidentificationof

themostrelevantmicrobial

agentsinH

AI

Determinationof

Clostrudiundifficile

Report,record,and

laboratoryinterview

Identifysusceptib

ilitypatternsforthemostfrequentag

entsor

thoseofepidemio

logicalimportanceforHAI

Methicillin-resista

ntStaphylococcusaureus

Vancomycin-resistantStaphylococcusaureus,withCIM

Report,record,and

laboratoryinterview

Diagnostic

capability

Vancomycin-resistantEnterococcus.

Report,record,and

laboratoryinterview

Enterobacteriaan

dnonfermentingbacillithatproduce

carbapenemasesandextended-spectrumbeta-lactama

ses(ESBL)

Report,record,and

laboratoryinterview

Hasroutineproceduresand

capacityto

identify

susceptibilityto

antimicrob

ialdrugsofHAI

agentsisolated

Nonfermentingbacilliproductiveofcarbapenemases

Report,record,and

laboratoryinterview

*

SeeGlossary.


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Theprogrammaintainsqualitycontrolrecordsonident

ification

ofagentsandantimicrobialsusceptibilitiesinaccordancewith

NCCLSorotherstandards

Report,record,and

laboratoryinterview

Theprogramissu

bmittedtoanexternalperformancee

valuation

programatleastonceayear

Reportfrom

referencelaboratory

Qualitycontrol

Microbiolo

gyactivitiesare

evaluatedperiodicallywith

internalan

dexternal

qualitycon

trol

Thereisamanualofproceduresforinternalqualitycon

trol,

updatedatleaste

very3years,whichisdisseminatedto

the

personnel

confirm

Thereisaspecimencollectionandshippingmanual,updatedat

leastevery3year

s,whichisdisseminatedtotheperson

nel

confirm

Specimen

collection,

processing,and

shipping

standards

Therearestandardized

techniques

andprocedures

Thereexistsaspe

cimenprocessingmanual,updatedat

least

every3years,whichisdisseminatedtothepersonnel

confirm

Periodicreporton

theagentsresponsibleforHAIbyspecimen

typeandthedepartmentoforigin

Howmanyinaye

ar?

Microbiologyreport

Periodicreporton

antimicrobialsusceptibilitypatternsfor

relevantetiologic

agents

Howmanyinaye

ar?

Microbiologyreport

andrecord

Microbiological

information

Clinicalinformation

analysis

Thereisanalertm

echanismforunusualmicrobiologica

lfindings

Reportandrecords

Alaboratorystaff

memberispartoftheHAIcontrolcommitteeof

controls

Records

Participationin

thecommitteefor

HAIprevention

andcontrol

Relationofthe

microbiolo

gisttotheHAI

controlcom

mittee

Participationofth

elaboratoryinthepreparationofma

nualsand

guidelinesoftheHAIcommittee

Confirm


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2

AREA:INTERVENTION

STRATEGIES

Component

Characteris

tics

Indicator

Suggestedverifier

Consolidated

activities1

Present?

Existenceofacompleteregulatorytechnicalbasis

Sta

ndards*,guides*o

r

ma

nuals*

Summarycolu

mn(a)

Theregulationshave

beenupdatedwithinthelast

threeyears

Sta

ndards*,guides*

or

manuals*

Summarycolu

mn(b)

Principalac

tivitiesforIPC

areregulatedin

accordance

withbest

currentknowledge

Thecontentsandind

icatorsofthetechnical

regulationsareevide

nce-based

Sta

ndards*,guides*

or

manuals*

Summarycolu

mn(c)

Theregulationshave

beendisseminatedwith

effectiveactivitiesto

thosepersonnelwhoshould

befamiliarwiththem

Tra

iningprogram

evaluated,attendance

rep

orts

Summarycolu

mn(d)

Supervision*ofcompliancewiththeregulationsby

personnel

Supervisionreports

Summarycolu

mn(e)

Interventionsto

improveHAI

preventionand

control

Compliance

with

regulations

ispromoted

andevaluated

Thereisevidenceof

compliancewiththebasic

regulations

Dir

ectobservation

Summarycolu

mn(f)

1

UsethePREVENTIO

NANDCONTROLSTRATEGIES

RECORDFORMtorecordthedetailedinformationconsolidatedhere.

*

See

Glossary.


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2

PREVENTIONANDCONTROLSTRATEGIESRECORDFORM

Characteristics

Infectionprevention

activities

(a)

Present

(b)

Updated

(